Three Stages or Bust?

PublishedApril 28, 2013

What is accepted as ‘Normal Labour’?

Most mainstream sources of information about birth, including magazines and antenatal classes portray labour as happening in 3 distinct stages, the first of which progresses over many hours or even days according to whether the woman is pregnant with her fourth or first baby respectively. These informants will also advise that when the accepted ‘safe’ time limits for each of these stages of normal labour are exceeded it is a sign that the woman’s body needs to be medically helped. This help can be in the form of treatments to speed the labour up (augmentation) or pull the baby out of the woman by using vacuum or forceps or major abdominal surgery.

Equally, a labour which occurs more quickly than with-in these prescribed boundaries is called “Precipitate Labour” and considered potentially dangerous for mother, baby or both. Though sometimes stunned by this unexpected and overwhelming experience of labour and birth, women and their babies are usually unharmed by ‘precipitate’ labours, particularly when compared to the levels of trauma experienced by many women who have medical ‘help’ with slow labours. Women I have known, who accept that labour is an unpredictable point on the continuum from sex to motherhood and one which their body is able to complete safely, do not report quick births as emotionally or physically traumatic. Rather like Dr Sarah Buckley, some women have recounted to me their deep awareness and connection to their baby’s birthing efforts which prompted their responses to and trust in the situation. On reflection these mothers find the birth experience as ‘enlightening’ about the personality of their baby or their life or state of mind at that time, which re-enforces their trust in their intuitive thought processes; a great foundation for parenting.

Meanwhile, annual reports on maternity outcomes show that each year more women in New Zealand hospitals need medical help to labour or deliver their babies. In 2010, 19.8% labours were artificially started or induced, 28.6% of labours were augmented, 24.9% women needed an epidural and 23.6% New Zealand labours ended in a Caesarean delivery, compared to 15.8% in 1995. UK Obstetrician and Epidemiologist, Dr Amali Lokugamage says “The leading drivers in the rising Caesarean section rates are the existing medical culture and preference for caesareans; the lack of optimum environment to elicit normal birth in medical establishments; changes in obstetric training; loss of maternal body confidence and fear of labour.” as the aforementioned NZ intervention trends are similar all around the developed world.

The description of labour, as occurring in 3 distinct stages originated when birth began to move from the intimacy of a woman’s home to unfamiliar hospitals in the 17th century. Analysis of events and, or clinical findings such as intrusive vaginal examinations are needed to determine when these stages have begun or changed as per the constraints of their definitions. For example; “Stage 1 of labour, commonly called “early labour”, begins when the woman experiences regular, rhythmic contractions and it is complete when the cervix has fully opened to around 10 cm dilated.”

Natural, instinctive or undisturbed labour.

However growing knowledge from the last 50 years, of how pregnancy and birth hormones interact with the woman’s internal and external environment, as well as each other, for the smooth natural initiation, progress and completion of healthy birthing, shows that any emotional or physical disturbance such as vaginal examinations or use of the woman’s thinking brain, can delay or even halt the flow of these crucial hormones, and thus stop labour. Even before this was understood home birth women and midwives perceived that such changes suggested that a woman may need to rest and recuperate for labour to progress. Encouraging a ‘nap’ or sleep between contractions actually reduces all sensory stimulation and thus supports the flow of endorphins (natural powerful pain-killers) as well as oxytocin from the deep, subconscious of a birthing woman.

Still these vital facts and related information are rarely featured in medically informed presentations about labour including in the ‘best seller’ pregnancy books recommended by Parent Centres NZ, most book stores and online. Thus the diagnosis, or blaming women’s wombs as inefficient with labels of ‘Inco-ordinate’ or ‘Uterine Inertia,’ is usually uncontested, as is the call to help with an artificial oxytocic drip or more. Intravenous oxytocin infusions contribute to a cascade of interventions as they require more monitoring and usually an epidural because the contractions become more painful, then the resulting loss of pelvic floor sensitivity can impede the baby’s movements to birth and so the baby may need a ‘little lift-out’.

Some ‘latent’ phases in women’s labours have become accepted in some hospitals and texts, though Sheila Kitzinger in 2010 recounted how the ‘Rest and be thankful’ time after full dilation (following a vaginal examination to diagnose the ‘end of first stage’) is a time when many UK midwives become anxious and exhort women to push with-out any urge to do so! More aware hospital midwives often have to manipulate situations such as staff shortage periods to divert interventions by other staff gaining time for women to rest and recuperate, when their hormones have been blocked by the hospital environment and its procedural requirements.

Most hospitals, and medical oriented maternity carers do not understand the many behavourial and bodily responses of women to the birthing movements of their baby which are signs of progress in labour, rather their practice centres on intrusive, subjective and contentious vaginal examinations. Nor do they value the ability to unobtrusively observe any indication of labour progress. These traditional midwifery sign posts of normal progress which promote, protect and support natural undisturbed or instinctive birth, were first shared with me by very senior midwives when I was a student, but now appear little known or used, even in home birth here and elsewhere.

Meanwhile the financial, social and emotional costs of intrusive, high-tech labour monitoring appear irrelevant issues, regardless of the true level of risk or drivers of adverse outcomes for healthy women, as near tragedies, the bizarre and blame games are the most common themes of New Zealand media reports about birth. Fear of birth or ‘Tocophobia’ is a growing epidemic in our culture which repeatedly presents labour as something that can take several days and result in the medical rescue of a woman and, or her baby. Equally, media ignore or even denigrate the knowledge and experiences of women who have quick or easy, which adds to the irrational fears, misinformation and myths about natural birth.

Maternity support groups seek to redress these issues through information presented on their websites and other undervalued, volunteer efforts. Thus despite or because of these hurdles the 2010 New Zealand home birth rate was 3.2% in 2010, with another 10.8% births occurring in primary care facilities; the other place where augmentation, epidurals and surgical deliveries cannot happen and the goal is to optimise normal birth. Meanwhile there is a united campaign by the UK colleges of obstetricians, midwives, National Childbirth Trust and UK parliaments to increase home and primary births there.

One effort to increase the number of New Zealand women who have a healthy, no or low intervention birth is the Maternity Manifesto which seeks support for;Normal Birth: Labour and birth which starts, progresses and ends naturally achieves the best outcomes for women, babies and whanau as well as uses less health resources. This should be the New Zealand gold standard or goal for maternity services with campaigns to monitor and improve such “normal birth” rates.

Alterntives to Hospital Birth: The place of birth dramatically affects birth outcomes. New Zealand needs promotion and support for healthy women to access birth centres or birth at home to increase “normal birth” rates, benefiting women, whanau and the community.

All change is not growth, as all movement is not forward.— Ellen Glasgow

Nothing in life is to be feared it is only to be understood. Now is the time to understand more so we can fear less.— Marie Curie

A loving heart is the truest wisdom.— Charles Dickens

Trust children. Nothing could be more simple, or more difficult. Difficult because to trust children we must first learn to trust ourselves and most of us were taught as children we could not be trusted.— John Holt

No other natural bodily function is painful and childbirth should not be an exception.— Grantly Dick-Read

We need to have their hearts before we can open their minds.— Dr Gordon Neufeld

Birth is not only about making babies. Birth is about making mothers – strong, competent, capable mothers who trust themselves and know their inner strength.— Barbara Katz-Rothman

Without deviation from the norm, progress is not possible.— Frank Zappa

I can promise you that women working together - linked, informed and educated - can bring peace and prosperity to this forsaken planet.— Isabel Allende

The greatest joy is to become a mother; the second greatest is to be a midwife.— Norwegian proverb